Disadvantaged Backgrounds Research Articles

COVID-19 Public Health Restrictions and Older Adults’ Well-being in Uganda: Psychological Impacts and Coping Mechanisms

ABSTRACT Objectives Older adults across the globe have been particularly affected by the novel coronavirus due to their increased susceptibility to the virus. With limited existing research, the aim of this study was to explore the psychological effects of COVID-19 public health measures on older adults in Uganda and their coping mechanisms. Methods Thirty semi-structured interviews were conducted with older Ugandans (aged 60+) in June 2020. Participants were asked about their experiences of public health measures, and their effects on the lives of older adults compared to pre-pandemic. Results Three themes were identified: Impact on emotional well-being; Implications on physical well-being; and Coping mechanisms. Older adults experienced both psychological and physical effects, including upset, fear, and frustration about restrictions and the virus, as well as early signs of increased frailty, thus causing concerns for the long-term emotional and physical health of older Ugandans. Conclusions Public health measures need to be considerate of the potential long-term implications on the well-being of older adults in low-, middle-, and high-income countries, and ensure the possibility for continued physical exercise and social connection. This can be particularly challenging for people from more disadvantaged backgrounds who may not be able to afford a smartphone or laptop, with older adults further requiring support in using digital technologies. Clinical implications Older adults need to receive adequate psychological support to cope with the mental health impacts of the pandemic.

γ‐Al2O3/triflic acid as cooperative catalysts for the tandem Michael addition/carbocyclization: An easy access to 2‐substituted pyrrolo[2,1‐a]isoquinolines and 3‐substituted pyrrolidine‐2,5‐diones

AbstractA tandem Michael addition/carbocyclization of 3,4‐dimethoxyphenethyl maleimide with carbon and sulfur nucleophiles is accomplished via a relay catalysis using γ‐Al2O3/TfOH binary system. The X‐ray Photoelectron Spectroscopy (XPS) analysis of binary system indicates the presence of AlF3, AlO(OH) species. This approach provides an easy access to 2‐aryl or 2‐thio aryl pyrrolo[2,1‐a]isoquinolines in good yields in a tandem fashion. With suitable ratio of γ‐Al2O3/TfOH binary system, the Michael addition of N/C/S nucleophiles to N‐benzyl maleimide is also achieved. A key to the success of these reactions would be the generation of AlF3, AlO(OH) species from γ‐Al2O3 and TfOH, which might have delineated the disadvantageous background reactions usually displayed by a strong Brønsted acid such as TfOH.

A mercenary army of the poor? Technological change and the demographic composition of the post-9/11 U.S. military

ABSTRACT We test two sets of alternative hypotheses about the demographic composition of the U.S. armed forces. We analyse individual-level data of two national representative samples covering the period 1979–2008. We find that, in contrast to the accepted wisdom, the U.S. military no longer primarily recruits individuals from the most disadvantaged socio-economic backgrounds. Technological, tactical, operational and doctrinal changes have led to a change in the demand for personnel. As a result, on different metrics such as family income and family wealth as well as cognitive abilities, military personnel are on average like the average American citizen or slightly better.

English

BACKGROUND Malignancy of oral cavity is quite a common disease entity in Western part of the state of Odisha. This is because of prevalence of habits like smoking, chewing tobacco, and consumption of alcohol. Ignorance about the severity of the condition in early stages leads to delayed diagnosis. METHODS A study was undertaken in Bhima Bhoi Medical College, Bolangir, in Western Orissa from October 2018 to September 2020 to study about different patterns of presentations and histopathological variations of malignancy of oral cavity in this part of Odisha. Patients were thoroughly clinically evaluated, examined, and appropriate investigation protocol was followed to record data. RESULTS About 0.33 % of all patients coming to the outpatient department (OPD) were found to be suffering from carcinoma of oral cavity. Maximum number of cases were males in the 5th and 6th decade with squamous cell carcinoma. Predisposing factors like areca nut and pan masala consumption were noted. A majority of patients were cultivators from lower middle-class families. Other common groups were businessman and industrial workers. They had come with burning sensation in the mouth and restricted mouth opening as complaints. Xerostomia, fibrous bands in mouth, cervical lymphadenopathy were signs that were detected. Cheek was seen to be a primary site of lesion in large number of cases followed by tongue and lip. CONCLUSIONS In spite of them being easily assessable, patients ignored their symptoms leading to delay in reporting to healthcare facility. As the patients were from disadvantaged background, by the time they came to hospital, they were in an advanced stage (stage three). Squamous cell carcinoma is very common in this part of Orissa. Proper guidance to the patients about the symptoms and risk factors will go a long way in early diagnosis and a more favourable outcome post treatment. KEYWORDS Malignancy, Oral Cavity, Predisposing Factor, Stage

Insurance coverage and health care use among children with diabetes.

Health insurance coverage may be associated with pediatric diabetes mellitus (DM) management. However, it is unknown how continuity of insurance coverage is associated with health care use outcomes in pediatric DM. We used the nationally representative 2016-2019 National Survey of Children's Health to examine how interruption of health insurance coverage may affect health care use among children with DM. Children ages 0-17 years with DM were included in the analysis. Outcomes included emergency department visits, specialist visits, and unmet health care needs in the last 12 months. Insurance coverage was classified as continuous private, continuous public, or discontinuous (including gaps in coverage and year-round lack of coverage). Based on a sample of 548 children, 56% percent had continuous private insurance coverage, as compared to 32% with continuous public insurance, and 12% with discontinuous coverage. Thirty-five percent of children had visited the ED in the past 12 months, and only 47% had visited any specialist in the past 12 months, including but not limited to a pediatric endocrinologist. An estimated 19% of children had unmet health care needs over the past 12 months. On multivariable analysis, children with coverage gaps were significantly less likely than children with continuous private coverage to have a visited a specialist in the past 12 months (adjusted odds ratio: 0.27; 95% CI: 0.08, 0.88; p = 0.030). This study points to a need to establish and maintain specialist follow-up for children with DM, especially those from socioeconomically disadvantaged backgrounds.

The development and efficacy of a mobile phone application to improve medication adherence for persons with epilepsy in limited resource settings: A preliminary study

ObjectivePersons with epilepsy (PWE), especially those with limited education backgrounds from developing countries, are challenged by complicated medication regimens, debilitating seizures, and stigmatization in their daily life. Consequently, it is difficult for physicians to ensure medication adherence. This study validates a novel mobile application which was hypothesized to increase medication adherence and self-management skills in PWE. Created by medical professionals, the application included behavioral and educational components and was built to be easy-to-understand for those of socio-economically disadvantaged backgrounds. MethodsThis was a parallel, two-armed randomized controlled trial in which a total of 96 participants were enrolled from a Neurology Outpatient Department into a control standard care group and a mobile application group that used the smartphone application (app) in addition to the standard medical treatment. The app was intuitive and easy to understand for those coming from a socio-economically disadvantaged background. Medication adherence and self-efficacy were assessed with the Morisky Green and Levine Scale (MGLS) and the Epilepsy Self Efficacy Scale (ESES). Patients were reassessed 12 weeks later. Change in seizure frequency following administration of the application was a secondary outcome. ResultsIn an intent-to-treat analysis, the mobile application interventional group showed over a 60% increase in the proportion of medication adherence (P < 0.0001). The mean self-efficacy score for the mobile application group was increased from 269.5 to 289.75 (P < 0.0001). The control group showed no statistically significant increases in either the proportion adherent or mean self-efficacy scores. SignificanceThis study demonstrated the statistically significant performance of a mobile application in improving medication adherence and self-management skills in Indian persons with epilepsy.

Who would be targeted by increasing the legal age of sale of cigarettes from 18 to 21? A cross-sectional study exploring the number and characteristics of smokers in England.

AimsTo establish the number of smokers in England who would be targeted by increasing the age of sale of cigarettes from 18 to 21 years and to assess the smoking and socio‐demographic profile of those smokers.Design and settingNationally representative cross‐sectional survey of adults in England conducted between January 2009 and July 2019.ParticipantsA total of 219 720 adults.MeasurementsAll participants reported their current smoking status and socio‐demographic characteristics (i.e. age, gender, home ownership, social grade and ethnicity). Smokers reported motivation to quit, urges to smoke and the Heaviness of Smoking Index (HIS). Weighted prevalence statistics were calculated. Multinomial regression and logistic regression were used to assess differences in smoking characteristics among smokers and socio‐demographic characteristics relative to non‐smokers.FindingsThe prevalence of smoking between January 2009 and July 2019 was highest among those aged 21–30. In 2019, 15.6% [95% confidence interval (CI) = 12.8–18.8%] of 18–20‐year‐olds reported smoking, which is estimated to represent 364 000 individuals in England. Relative to smokers aged 18–20, older smokers (aged 21+) had a higher motivation to quit smoking [odds ratios (ORs) = 1.40–1.45 range] and higher nicotine dependency as measured by urges to smoke (ORs = 1.06–1.24 range) and HSI (ORs = 1.05–2.85 range). Compared with non‐smokers aged 18–20, smokers in this age group had lower odds of being female (OR = 0.89) and higher odds of being of white ethnicity (OR = 2.78) and from social grades C1–E (lower social grades) compared with AB (higher social grades) (OR = 1.19–1.83 range).ConclusionIncreasing the age of sale of cigarettes to 21 years in England would currently target approximately 364 000 lower dependent smokers from more disadvantaged backgrounds aged 18–20, who have less motivation to quit.

963 Can telemedicine improve postpartum access to care?

During the COVID19 pandemic, telemedicine has become a common modality for postpartum care. Given the importance of postpartum visits to women’s healthcare and the disproportionate impact on patients from minority and disadvantaged backgrounds, we aim to evaluate the effect of telemedicine on postpartum attendance in this patient population. This is a retrospective cohort study comparing postpartum attendance of a cohort prior to implementation of telemedicine (PTM) in June 2019 and a cohort of patients post telemedicine implementation (TM) in June 2020. We included all patients who received prenatal care and delivered at our institution and excluded any patients who delivered prior to 24 weeks. We compared characteristics and outcomes between the PTM and TM cohorts. Primary outcomes were any in-person or telemedicine postpartum visit attendance within 6 weeks and 12 weeks of delivery. Secondary outcomes included completion of a comprehensive postpartum assessment (CPA), number of ED visits, and number of readmissions within the postpartum period. A total of 589 patients were studied across the PTM (275) and TM (314) cohorts. A majority of patients were Black (31%) or Hispanic (41%), and most had public insurance (75%). The unadjusted rate of attendance within 6 weeks was higher in the TM cohort (72.6% vs. 64.4%, p=0.03), however there was no difference in postpartum attendance within 6 or 12 weeks after adjusting for demographic and clinical characteristics. There were more patients with completed CPA (47.5% vs. 27.2%, p<0.0001) within 6 weeks in the PTM cohort. There was no difference in rate of ED visits or postpartum readmissions within 6 weeks. Telemedicine allowed for similar rates of attendance and care at postpartum visits overall, with a trend toward increased postpartum attendance prior to 6 weeks. However, in-person visits allowed for a higher rate of CPA. This suggests that telemedicine may allow for earlier postpartum attendance but will need to be improved to provide more comprehensive care for postpartum women.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Relationship between obesity and lower rates of breast feeding initiation in regional Victoria, Australia: an 8-year retrospective panel study

ObjectivesUsing routinely collected hospital data, this study explored secular trends over time in breast feeding initiation in a large Australian sample. The association between obesity and not breast feeding was...

Academic resilience: underlying norms and validity of definitions

Academic resilience refers to students’ capacity to perform highly despite a disadvantaged background. Although most studies using international large-scale assessment (ILSA) data defined academic resilience with two criteria, student background and achievement, their conceptualizations and operationalizations varied substantially. In a systematic review, we identified 20 ILSA studies applying different criteria, different approaches to setting thresholds (the same fixed ones across countries or relative country-specific ones), and different threshold levels. Our study on the validity of these differences and how they affected the composition of academically resilient students revealed that the classification depended heavily on the threshold applied. When a fixed background threshold was applied, the classification was likely to be affected by the developmental state of a country. This could result in an overestimation of the proportions of academically resilient students in some countries while an underestimation in others. Furthermore, compared to the application of a social or economic capital indication, applying a cultural capital indicator may lead to lower shares of disadvantaged students classified as academically resilient. The composition of academically resilient students varied significantly by gender and language depending on which indicator of human capital or which thresholds were applied reflecting underlying societal characteristics. Conclusions drawn from such different results depending on the specific conceptualizations and operationalizations would vary greatly. Finally, our study utilizing PISA 2015 data from three countries representing diverse cultures and performance levels revealed that a stronger sense of belonging to a school significantly increased the chances to be classified as academically resilient in Peru, but not in Norway or Hong Kong. In contrast, absence from school was significantly associated with academic resilience in Norway and Hong Kong, but not in Peru.

Current Perspectives on Management of Type 2 Diabetes in Youth.

The prevalence of type 2 diabetes mellitus (T2DM) in children and adolescents is on the rise, and the increase in prevalence of this disorder parallels the modern epidemic of childhood obesity worldwide. T2DM affects primarily post-pubertal adolescents from ethnic/racial minorities and those from socioeconomically disadvantaged backgrounds. Youth with T2DM often have additional cardiovascular risk factors at diagnosis. T2DM in youth is more progressive in comparison to adult onset T2DM and shows lower rates of response to pharmacotherapy and more rapid development of diabetes-related complications. Lifestyle modifications and metformin are recommended as the first-line treatment for youth with T2DM in the absence of significant hyperglycemia. Assessment of pancreatic autoimmunity is recommended in all youth who appear to have T2DM. Pharmacotherapeutic options for youth with T2DM are limited at this time. Liraglutide, a GLP-1 agonist, was recently approved for T2DM in adolescents 10 years of age and older. Several clinical trials are currently underway with youth with T2DM with medications that are approved for T2DM in adults. Bariatric surgery is associated with excellent rates of remission of T2DM in adolescents with severe obesity and should be considered in selected adolescents.

Propuesta de formación docente para profesores universitarios

La formación docente universitaria debe ofrecer las herramientas que permitan al equipo de profesores desarrollar las competencias en sus estudiantes para hacer frente a un entorno complejo e incierto. El objetivo de este artículo es presentar una alternativa de formación para docentes universitarios que responda a las demandas de la sociedad actual. Se fundamenta en la teoría del aprendizaje transformador de Mezirow, el constructivismo sociocultural de Vygotsky y el concepto de comunidades de aprendizaje. Por tratarse de una propuesta enmarcada en una universidad jesuita, se retoma un elemento central de su modelo educativo: la pedagogía ignaciana. En virtud de las dificultades de algunos estudiantes en su proceso de incorporación a la universidad, la propuesta está enfocada a los docentes de primeros semestres, aunque se prevé extenderla paulatinamente a todo el equipo docente. Se espera que este modelo de formación derive en la igualdad de oportunidades de éxito académico para todas las y los estudiantes, especialmente para quienes provienen de entornos desfavorecidos y que se incorporan a programas de nivel Técnico Superior Universitario, o bien, de licenciatura.

Current Perspectives on the Role of Very-Low-Energy Diets in the Treatment of Obesity and Type 2 Diabetes in Youth.

In both developed and developing countries, pediatric obesity and type 2 diabetes are an increasing public health concern: globally 5.6% of girls and 7.8% of boys aged ≥5 years have obesity. The incidence of type 2 diabetes has increased in youth in recent decades and disproportionately affects those from ethnic/racial minority groups and disadvantaged backgrounds. For the treatment of both conditions, conventional lifestyle intervention is frequently ineffective, access to bariatric surgery is very limited and many young people are unsuitable or unwilling to undergo surgery. A very-low-energy diet (VLED) provides a viable alternative and may be effective for weight reduction and improved glycemic control in youth, based on one systematic review. In particular, in the treatment of type 2 diabetes, a chart review and a pilot study both demonstrated that a VLED can reduce the requirement for medications, including insulin, and lead to the remission of diabetes. However, long-term follow-up and safety data remain limited and therefore a VLED is inconsistently recommended by clinical practice guidelines for the treatment of pediatric obesity and type 2 diabetes. In clinical practice, VLED use in children and adolescents is uniquely challenging due to intolerance of expected side effects, difficulty adhering to the highly restrictive diet and difficulty with behaviour change within the current social context and environment. Ultimately, more research, including larger, longer-term trials with comprehensive safety monitoring are required to strengthen the evidence base. This would inform clinical practice guidelines, which may facilitate more widespread utilization of VLED programs in the management of obesity and type 2 diabetes in youth.

Self-Assessment of Engineering Learners’ Perception of Usefulness of Pre-Writing Strategies

The engineering undergraduate students at premiere institutions give more importance to core subjects often neglecting the English language. Specifically, these students consider academic writing less important than other language skills such as speaking, reading, and listening. As a result, these students are at a big disadvantage in the industry and while applying for higher education. Hence, the present study has attempted to understand the students’ perceptions of usefulness of pre-writing strategies. For this purpose, 439 engineering undergraduate students (357-males and 82-females) have been administered a self-assessment questionnaire of pre-writing strategies. The main research tools used in this study were a structured self-assessment questionnaire and informal interviews with the students. The quantitative data was analyzed through statistical procedures in SPSS-26 software. The analysis of the students’ interviews was described. The findings showed that the majority of the engineering students have positive perception towards the usefulness of pre-writing strategies. The results revealed that there was no significant difference between the male and female students’ perceptions of usefulness of pre-writing strategies. The study recommends improving engineering students’ pre-writing strategies and also proposes remedial teaching for fostering basic ESL writing requirements of students who come from disadvantaged backgrounds.

Educational needs of the primary education teachers in inclusive education of the pupils from socially disadvantaged backgrounds in Slovakia

The study presents the results of the research examining the educational needs of the teachers and their interest about the themes of courses and educational programmes in connection with actual needs arising from changes in the Slovak education system due to the gradual promotion of inclusion. The main research method was the questionnaire aimed at detection of primary level teachers’ needs for the professional development and trainings, the identification of primary education teachers’ needs for successful implementation of inclusion in the learning of the pupils from socially disadvantaged backgrounds. This study presents if there exist statistically significant differences in self-reflexive perception of the need to improve in topics related to the implementation of inclusive education and the characteristics of respondents (age, length of the teaching practice, willingness to grow personally and to educate).

Adolescent Fathers' Perceptions and Experiences of Fatherhood: A Qualitative Exploration with Hispanic Adolescent Fathers

The purpose of this secondary analysis of qualitative data was to understand the multifactorial influences that impact the health and health behaviors of Hispanic adolescent fathers DESIGN & METHODS: Qualitative description was the method used for this secondary analysis. The theoretical domains of the Vulnerable Populations Conceptual Framework were used to guide this study. The semi-structured interviews of 17 participants were analyzed using qualitative content analysis. Participants were Hispanic adolescent fathers, between the ages of 16 and 23 years, who were attending a fatherhood program. Most participants came from socioeconomically disadvantaged backgrounds and unstable families. Additionally, their exposure to widespread neighborhood and domestic violence resulted in gang involvement and illegal activities. The cumulative impact of adverse childhood events resulted in substance use and psychological distress. However, becoming a father was transformative, motivating adolescents to stop engaging in destructive, unhealthy behaviors. Adolescent fathers' well-being is an important component of perinatal health because it affects family functioning and health outcomes in their children. The perinatal period presents a "golden" opportunity to promote health and should be leveraged by nurses to allow adolescent fathers to become involved during the perinatal period. A family-centered approach is critical in addressing the complex needs of this population. An assessment of their psychosocial environment, including childhood trauma, is necessary to help nurses identify at-risk fathers. Additionally, trauma informed care is a valuable tool that nurses can utilize to foster trust in Hispanic adolescent fathers.

What Solutions Exist for Developmental Delays Facing Indigenous Children Globally? A Co-Designed Systematic Review.

Early childhood is important for future cognitive and educational outcomes. Programs overcoming barriers to engagement in early education for Indigenous children must address family cultural needs and target developmental delays. This systematic review identifies culturally adapted programs to improve developmental delays among young children, in response to an identified priority of a remote Indigenous community. Five databases (the Cochrane Library, Embase, Medline, Scopus and CINAHL) were searched for English language papers in January 2018. Study quality was assessed, and findings were analysed thematically. Findings were presented to the community at an event with key stakeholders, to determine their inclusion and face validity. Seven relevant studies, published between 1997 and 2013, were identified by the researchers and each study was supported by the community for inclusion. Three studies included on Native American children and four studies included children from non-Indigenous disadvantaged backgrounds. Findings were reported narratively across four themes: storytelling to improve educational outcomes; family involvement improved development; culturally adapted cognitive behavioural therapy to reduce trauma; rewards-based teaching to improve child attention. Limited published research on culturally adapted and safe interventions for children with developmental delays exists but these four themes from seven studies identify useful components to guide the community and early childhood program development.

Gender matters: family background and upper secondary education in Finland

The intergenerational transmission of education and social position is a widely studied topic, but measurement of the significance of gender in this subject has received less attention. We study gender differences in the effect of parental disadvantage on the probability of a child completing upper secondary education in Finland. We use high-quality register data, collected by Statistics Finland. The data are clustered according to families that includes information on both children and their parents. The data consist of a 25 per cent sample of persons born in Finland between 1980 and 1986 (n=157,135). The data are analysed using sibling methods using random-effects linear probability models. The analyses are run separately for daughters and sons. With the exception of parental unemployment, all the indicators measuring disadvantaged parental background are significantly more strongly connected to the probability of sons than the probability of daughters completing upper secondary education. Father’s unemployment is a stronger predictor of the child’s probability of completing upper secondary education than unemployment of the mother. The mother’s educational level predicts a child’s probability of completing upper secondary education more strongly than the educational level of the father. Both mothers’ and fathers’ educational levels have a significantly stronger correlation with sons’ than daughters’ completion of upper secondary education. Equality of opportunity seems to be achieved better among girls than among boys. It might be the case, that the educational system, as one of the most important paths for achieving superior social status to one’s parents, does not treat girls and boys equally. Were this so, it would be especially important to pay more attention to boys’ school readiness and school wellbeing, especially in socioeconomically disadvantageous areas.

The Determinant and Impact of Child Labor on Children’s Education Performance in Chiro Woreda-Western Hararghe Zone - Oromia National Regional State-Ethiopia

This study attempted to assess the Determinants of child labour and its effects on the Children’s schooling: the case of chiro Woreda, Oromia, Ethiopia. The objective of the study was to identify the working conditions of child laborer’s, to assess the factors that determine children decision to participation in work, school or a combination of them and also to assess the effect of child labour on the children’s schooling. The study conducted using 220 child laborer’s respondents. Both quantitative and qualitative data were collected by using survey method and focus group discussion. The findings of the study indicate that nearly all the child workers that participated in the study were with disadvantaged background involving coming from poor families, some being orphaned and having migrated from other parts of Oromia as well as from neighboring South and Amhara region to chiro Woreda. Hence, the majority of the child laborer’s in this study found either illiterate or school drop outs, therefore policy measures that resort child workers from work to school should be put in place so as to make public schools well equipped and attractive to children and their parents. Keywords: child labor, determinant, education, impact and labor DOI: 10.7176/RHSS/10-23-04 Publication date: December 31 st 2020

Does Community College Attendance Affect Matriculation to a Physician Assistant Program? A Pathway to Increase Diversity in the Health Professions.

To explore whether community college (CC) applicants were a significant contributor to the diversity of matriculants to physician assistant (PA) programs and whether CC applicants were less likely to matriculate to PA programs than non-CC applicants. The authors used national data from the 2016-2017 application cycle. They categorized applicants to PA programs into 5 pathways: HS-CC (applicant attended CC while in high school), first-CC (applicant attended CC before a 4-year university), 4Y-CC (applicant attended CC while at a 4-year university), post-CC (applicant attended CC after graduating from a 4-year university), and no-CC (applicant never attended CC). The authors used Pearson chi-square and Kruskal-Wallis H tests and the appropriate post hoc tests to assess whether applicants in the 4 CC pathways were more diverse in terms of their race, ethnicity, gender, rurality, and socioeconomic status than those in the no-CC pathway. They used logistic regressions to assess associations between the CC pathways and matriculation to a PA program. Among the 8,577 matriculants in the 2016-2017 application cycle, more than 75% attended a CC at some point. First-CC and post-CC matriculants were more likely to be Black (P < .001) or Hispanic (P < .001) and come from a disadvantaged background (P < .001) than no-CC matriculants. After adjusting for applicant demographics, academic performance, rurality and socioeconomic status, and application strategy, first-CC applicants had 17% lower odds of matriculating to a PA program than no-CC applicants (P < .001). CCs are an important pathway to the PA profession, with 3 of 4 matriculants having a CC background. However, lower matriculation rates among similarly qualified applicants who transferred from a CC to a 4-year university than among applicants with no-CC background suggest that PA programs are missing important opportunities for increasing student diversity and thereby the profession.